Malaria frontline project: pre-intervention Malaria baseline assessment in Kano and Zamfara States, August 2016

Introduction In 2016, the Centers for Disease Control and Prevention and the Government of Nigeria initiated the Malaria Frontline Project in Kano and Zamfara States. The project goal is to improve the quality and coverages of malaria interventions adapting polio program strategy. We conducted a baseline assessment of malaria interventions. Methods Twenty-four primary health centers per State were selected using probability sampling. Health workers (HW) were purposively sampled to assess their knowledge of national malaria control guidelines. Clients were selected for exit interview to assess health workers´ adherence to the national guidelines. WHO cluster methodology was used to survey heads of household and women of reproductive age on knowledge of malaria prevention, Long Lasting Insecticidal Net (LLIN) ownership and use. Results Of the 158 HW interviewed, 94.3% knew the correct criteria for malaria diagnosis, 86.1% reported using artemisinin-based therapy to treat uncomplicated malaria. About 45% of HW reported prescribing artemisinin-based combination therapy (ACT) for uncomplicated malaria in first trimester of pregnancy and 39% prescribed quinine. Only 73.9% of fever cases were referred to laboratory as recommended by the national guideline. Households with one LLIN per 2 persons (Kano: 27.1%; Zamfara: 30.0%), LLIN use (Kano: 70.8%; Zamfara: 81.6%) and IPTp1 (Kano: 38.6%; Zamfara: 33.3%). Conclusion most clinicians have knowledge of national guidelines, but fewer adhere to guidelines in practice. Population LLIN ownership, LLIN use among pregnant women and IPTp are lower than the national targets of 58%, 83% and 75% respectively for 2016. We recommend improving health workers´ technical capacity and adherence to national malaria guidelines.


Introduction
Globally, an estimated 216 million cases of malaria occurred in 2016 with 445,000 deaths. Nigeria contributed 27% of the cases, the largest proportion of any country [1]. Despite progress made in the past decade to scale up malaria control interventions, malaria burden in Nigeria remains unacceptably high. To leverage the substantial human and technical capacity within the National Stop Transmission of Polio Program (NSTOP) and Nigeria Field Epidemiology and Laboratory Training Program (NFELTP), the Malaria Frontline Project (MFP), a collaborative 3-year initiative to support the Nigeria National Malaria Elimination Program (NMEP), was launched with support from the US Centers for Disease Control and Prevention (CDC). The MFP´s goal is to improve the quality of implementation of WHO recommended malaria interventions being supported by malaria partners. The objectives of the project are to: 1) strengthen technical capacity of health workers to implement quality malaria intervention at the local government area (LGA). 2) Improve the quality of malaria surveillance and facilitate evidence-based decision making to increase Nigeria´s public health capacity to prevent, detect, and respond to epidemics and other endemic high-impact diseases. The MFP builds on the experiences of NSTOP from the polio eradication and Ebola responses to strengthen health workers´ capacity to analyze and use malaria surveillance data for decision-making [2][3][4][5]. The MFP is collaborating at the field level with other malaria stakeholders including the US President´s Malaria Initiative (PMI), UK Department of International Development (DFID), WHO and UNICEF [5][6][7]. Kano and Zamfara States were selected for the MFP implementation because of high political commitment from State authorities, high malaria burden but scarce resources related to technical capacity. The MFP has technical staff at national, State, and LGA levels who support the technical work of malaria program staff and other HWs. The MFP staff at LGA are known as National Stop Transmission of Polio Local Government Officers (NSLOs). The MFP uses the Comprehensive Quality Improvement method (CQI), so staff meet regularly to analyze identified problems, find appropriate solutions and modify implementation strategy accordingly. The MFP has adapted NSTOP´s polio eradication thematic training approach of didactic classroom teaching followed by field assignments. The NSLOs join the malaria team at the LGA level for on-the-job mentoring during health facility supportive supervisory visits. Identified problems from these field visits are noted for team discussions and solution at monthly team meetings. A cross-sectional malaria baseline assessment was conducted in August 2016 to assess the status of Malaria control implementation in Zamfara and Kano States just before commencement of the project. The team assessed knowledge and practices of HWs on malaria diagnosis and treatment, community knowledge of malaria interventions, intermittent prophylactic treatment in pregnancy (IPTp) coverage, Long-lasting insecticidal net (LLIN) ownership and use. Results from the assessment informed the contents of the manuals prepared for the thematic trainings of staff to improve program implementation. The assessment will also serve as the baseline to measure the effect of the project on key malaria indicators at the end of the project.

Study area
The study areas are in Kano and Zamfara States, north-west geo-political zone of Nigeria (Figure 1). At the time of the baseline assessment, Kano State had a population of 12,945,338 (projected from 2006 census) with over 1,000 Primary Health Care units (PHCs), 36 general hospitals (GHs) and 2 tertiary facilities. Zamfara had a population of 4,466,775 (projected from 2006 census) with nearly 700 PHCs, 19 GHs and 1 tertiary facility. Both States have a cadre of public health professionals who are graduates of the NFELTP and now employed by NSTOP. These public health professionals are supporting polio eradication and helping to improve routine immunization services. From the 2015 National Malaria Indicator Survey (NMIS), the prevalence of malaria parasitemia was 60.2% and 69.9% in Kano and Zamfara, respectively, by malaria rapid diagnostic test (RDT) among eligible children of 6-59 months. The percentage of households with at least one LLIN was 88% and 89%, in Kano and Zamfara States, and LLIN use the night before survey was 43.8% in Kano and 56.3% in Zamfara [8]. MFP is implemented in every health facility of all the 14 LGAs of Zamfara State and every health facility in 20 of the 44 LGAs in Kano State. The restriction to 20 LGAs in Kano State was due to availability of project funds. The malaria program is supported by PMI and other partners in Zamfara State and by DFID and other stakeholders in Kano.
This was a cross-sectional study of health workers, care seekers and community members. The health worker assessment involved key informant interviews and an assessment of knowledge and practices in malaria diagnosis and treatment. Care seekers from Outpatient Department (OPD) were interviewed after receiving medical services and exiting from the primary health center (PHC) to ascertain HWs adherence to the national malaria guidelines of testing all febrile cases for malaria. Client exit interviews were conducted at PHCs but not at general hospitals (GHs). For community members, the heads of household and women of reproductive age (15-49 years) in the household were interviewed on knowledge on malaria prevention, Intermittent Preventive Treatment (IPTp), LLIN ownership and use.

Sampling
For the health facility assessment, probability based on patient load was used to select 24 PHCs in each State. Though 24 PHCs were selected per State, 23 facilities were actually surveyed in each State. One PHC was inaccessible in each State due to security reasons and the inaccessible facilities were not replaced. The general hospital serving as referral facility for the selected PHCs were also included in the survey. In each health facility, the staff attending to patients and the facility head were interviewed (158 HWs). A maximum of five individuals seeking services at the OPD because of fever on the survey day were consecutively and purposively selected for exit interview to ascertain HWs adherence to the national guidelines on malaria diagnosis. One hundred and thirty-one patients with fever visiting OPD participated in the client exit interview.
The household survey was conducted using the WHO cluster survey methodology; 30 computer generated enumeration areas (EAs) were selected for each State. The EAs are clusters of households arranged by population size in descending order; 30 were selected using determined sampling interval based on number of EAs. A cluster is a primary sampling unit serving as base for census enumeration. The National Population Commission has a list of 20,249 clusters in 20 LGAs in Kano State and 17,449 cluster in the 14 LGAs in Zamfara State. The cluster sampling was followed by selecting seven households (HHs) in each cluster. A starting point within each cluster was identified using Orux-mapping through android mobile phone with GPS technology. Facing north, the first HH was identified and subsequent selections were made by making a right turn until seven eligible HHs were interviewed. Overall, 210 households (7 households from 30 clusters) were surveyed in each State.

Data collection
Fourteen survey teams were formed for Zamfara and 20 teams were formed for Kano (one team for each LGA). The survey team consisted of personnel from the NSTOP, NFELTP residents, NMEP and Ministry of Agriculture. A survey team was made up of 3-4 data collectors (NFELTP residents) and one supervisor who was an NFELTP graduate. The teams were trained on how to access and administer the questionnaires and enter data using the Open Data Kit (ODK), an android-phone base data collection program. At each health facility, two HWs (head of facility and a HW who attends to patients) were interviewed using a structured questionnaire for their knowledge and practice of malaria case management. A questionnaire was also used for the client exit interview.
In the community, the household head was interviewed for household net coverage and eligible women of reproductive age were interviewed for their knowledge on malaria illness, treatment, IPTp, LLIN ownership and use. Women were interviewed with the assistance of a female interpreter fluent in both English and the local language, Hausa. A community member engaged by the survey team introduced the team to the household and was present during the interview to conform with the cultural norms of the study population.

Data quality control, processing and analysis
MFP staff coordinated the survey. NFELTP graduates with at least three years´ experience in public health supervised the assessment team. Team supervisors cross-checked data collected at the end of each day before the data management team upload the cleared data on web-based platform. Data entry, cleaning and analysis were conducted using SPSS Software version 20. Descriptive statistics were conducted on categorical datasets. The questionnaires allowed multiple answers to a question. The results were not adjusted for sampling.

Ethical consideration
Ethical approval for the assessment was obtained from Kano and Zamfara State Institutional Review Boards; the survey was approved as a nonresearch activity by the Office of the Associate Director for Science, Center for Global Health at CDC. Oral informed consent was obtained from HWs while written consent was obtained from household survey respondents and participants of client exit interviews.

Health workers´ knowledge and practices on malaria treatment
One hundred and forty-nine (94.3%) of the respondents had "correct" knowledge of the diagnostic criteria (clinical symptoms plus parasitological confirmation) for malaria. Of the HWs interviewed, 136 (86.1%) reported prescribing artemisinin-based combination therapy (ACT), the NMEP recommended first-line treatment for uncomplicated malaria. Small proportions mentioned using chloroquine (6.3%), and antibiotics (5.7%) for malaria case management, although these are not recommended drugs for malaria treatment by NMEP (Table 1, Table 2).

Health workers practices on treatment of Malaria in pregnancy
Of surveyed HWs, 39.9% reported treating uncomplicated malaria in the first trimester of pregnancy with quinine, 45.6% prescribed ACT and 20.3% prescribed sulphadoxine-pyrimethamine (SP). In the second and third trimester of pregnancy, ACT was the most commonly used drug for uncomplicated malaria treatment (80.4%) followed by quinine (19.0%). The national guidelines recommend quinine during the first trimester and ACT in the second and third trimester ( Table 3, Table 4).

Client exit interview
A total of one hundred and thirty-one clients with fever were interviewed in the 46 PHCs. Of these, 74.5% were referred by HW for laboratory confirmation of malaria diagnosis as recommended by the national guidelines. Over 80% received their laboratory result in less than 1 hour and almost 90% of all laboratory referred patients returned with their results to the HW. However, only 76.1% received explanation of their results from the HW (Table 5).  (Table 6).   (Table 7).

Discussion
The assessment found that most HW were knowledgeable of the national malaria guidelines especially diagnosis and treatment of uncomplicated malaria. The national guidelines in 2016 recommend quinine for treatment of uncomplicated malaria in first trimester but over a third of HWs said they would use SP or ACT to treat malaria illness in pregnant women in their first trimester. Our study revealed high awareness of cause, symptoms, at-risk groups, and prevention practices for malaria among women 15-49 years of age. However, there was low awareness among women interviewed on use of ACT for malaria treatment.  [9,10]. There is therefore an urgent need to strengthen other routes of LLIN acquisition.
Key informants in both States mentioned regular use of RDTs for malaria confirmation. This would reduce presumptive treatment of all fever cases as malaria and therefore generate higher quality data for malaria surveillance. Unfortunately, this was not the observation from HW practice through exit client interview.
Based on HW responses, ACTs were the most common medicines administered for malaria treatment. This may be due to the acceptance of the national policy on malaria treatment, which recommends ACT as the drug of choice, and the availability of job aids on the new national malaria guidelines and capacity building of health workers. However, a small proportion of health workers still prescribed non-recommended medicines, such as chloroquine and ACT or SP in the first trimester for pregnant women, contrary to national guidelines.

Limitations
During the data review different versions of registers were in use in health facilities (2010 and 2013 versions). The sampling strategy and statistical analysis used in the health facility and community surveys are not intended to produce representative population-based estimates. Our methods were meant to provide practical and actionable data for local health planners and managers and should not be interpreted in the same way as estimates from systematic national or statewide surveys like Malaria Indicator Survey (MIS) or Demographic Health Survey (DHS).

Conclusion
We recommend continuous orientation on the national guidelines and supportive supervision from higher levels to ensure adherence to the guidelines. There should be frequent problem-solving trainings for HW. Alternate sources should be explored to increase access to LLIN for the community. Prevention of malaria in pregnancy is important and need strategy to increase IPTp coverage. Non-recommended antimalarials like chloroquine should be withdrawn from circulation in public facilities.